Analysis on Nursing case study of Emily Smith

Question

Task:
Case scenario: A Nursing Case Study of Emily Smith
Emily Smith is a 53 year old woman who has been admitted to your surgical ward for the drainage of a Bakers Cyst. She is mother of five children and lives in a rural Victorian town. She has been married to Frank who is an electrician, for 28 years. They live on a farm, tending to be self-sufficient growing their veggies, some fruit and have chicken and cows.

She was diagnosed with Type 2 Diabetes Mellitus (T2DM) 6 months ago, during a routine workup for surgery. She takes no specific medication for her diabetes, and has been told by her GP to ‘watch what she eats’. She was devastated to discover her diagnosis of T2DM, as she was aware of the risks due to her family history. She has not returned to her GP since her initial diagnosis. She has no other past medical history of note. Emily says tearfully “I have been trying to eat right and exercise, but I can’t walk because of the pain in my knee and I was feeling down and eating ice cream. I have hardly eaten anything in the last week because I am trying to lose weight and get my blood sugar down.”

Her mother and older sister were both diagnosed with T2DM in their early 50’s.

Emily tells you she has had the Bakers Cyst for about 2 years. It has been increasing in size over the last 8 months, restricting her movements. The planned surgery is drainage followed by two follow up cortisone injections.

On Admission at 0800 - her blood glucose level (BGL) was 22.9 mmol/L [3.9-6.1 mmol/L]; HbA1c: 11% [normal <6.5%]. She has been fasting since midnight. She notes that she is feeling quite “stressed” about the surgery. On admission the following were recorded:

• Height: 167cm
• Weight: 105kg
• Blood Pressure: 140/80 mmHg
• Pulse rate: 95 beats/min
• Respiratory Rate: 22 breaths/minute
• Temperature: 36.7 ºC
• SpO2: 97%

Part 1 Questions (1000 words):
Emily is distressed that her blood glucose level is elevated and asks you for help in understanding her diabetes. She tells you that she has a friend who is very overweight, eats lots of cake and hardly ever exercises, and he does not have diabetes. Include an introduction or prelude (50 words)

1.1. Describe the pathophysiology of T2DM with links to Emily’s case. Include in your answer risk factors for T2DM, the pathogenesis of T2DM, possible complications of T2DM and outline the 3 levels of treatment options for T2DM. (550 words)

1.2. Differentiate between T2DM and T1DM (at least 5 differences). (100 words)

1.3. Identify at least 2 reasons Emily’s BGL is high on admission. Discuss how each reason you identify affects BGLs. (300 words)

Part 2 Questions (700 words):
The surgery is successful and Emily comes to see you in the outpatient clinic for cortisone injections (Kenacort-A 40). She has been commenced on metformin (APO-Metformin Tablets) and glipizide (Minidiab Tablets) to help control her diabetes. Her blood test on this visit was BGL 8.8 mmol/L [3.9-6.1 mmol/L]; HbA1c: 8% [normal <6.5%].

2.1. Discuss the three medications Emily is on. Include in your answer the action, complications/side effects and nursing considerations linked to Emily’s situation. (500 words)

2.2. Discuss the two blood results, one from prior to surgery and one from the clinic visit of Emily’s BGL and HbA1c. What are they? What do they measure and why have they changed? (200 words)

Part 3 Questions (300 words):
Ten years later, Emily is now 63 years old, she became concerned with her feeling of increasing tiredness, nausea and general pruritus. She visited her GP, who found her BP to be 190/110mm Hg. Although she is not diagnosed with hypertension, she admitted getting severe headaches and sometimes palpitations for over 5 years, when she was worried about the drought. She has been taking Ibuprofen and naproxen for the osteo-arthritis for nearly 5 years but did not seek medical help as she they would settle her discomfort. The GP referred Emily to a nephrologist who performed a renal function test. Her blood results were:

• GFR (glomerular filtration rate) was found to be 10ml/min/1.73m2 [90 to 120 mL/min/1.73 m2 ]
• Hb (Haemoglobin) was 95g/L [120 to 155 grams/L for female]
• Serum Potassium was 5.7 mmol/L [3.6 to 5.2 mmol/L]
• Serum Urea 17 mmol/L [2.9-8.2 mmol/L]
• Serum Creatinine 150 ?mol/L [50-110 ?mol/L]

3.1 What does Emily’s renal function test indicate? Explain her renal function test. What appropriate treatment should be available to Emily? Explain her treatment options with rationale (250 words) Add a conclusion in your own words (no new reference should be added in the conclusion) (50 words)

Answer

Introduction
The report below will be discussing the nursing case study of a woman named Emily Smith, who is a 53-year-old. She was admitted to the surgical ward of a hospital for having Bakers Cyst. So, based on the nursing case study background, the report will be highlighting different aspects related to Emily smith.

Part 1
1.1. In the nursing case study of Emily Smith, it can be seen that she is suffering from diabetes from the last 3 months, which may have occurred due to her obesity or it may genetic. Hence, the pathology of T2DM related to obesity is that visceral adiposity escalates the development of insulin resistance and led to type2 diabetes. The increased adipose tissues contribute to providing energy to the cells, hence the cell stops utilizing the glucose for cellular energy. The amount of glucose in the blood increases beyond the requirement of the cell, which leads to diabetes in obese people. The Pathophysiology behind T2DM with genetic factors is that, if the parent is having diabetes for a prolonged time then there is a probability that the gene consisting of diabetes features might also get transferred to their children (Zheng, Ley & Hu, 2018).

The factor that increases the risk factor of the type 2 diabetes is excessive weight, improper fat distribution, lower physical activity, family history, ethnicity or race, age, and pre-diabetic phase. Other than that, it also includes gestational diabetes, and polycystic ovarian syndrome (Chatterjee, Khunti & Davies, 2017).

The pathogenesis of type 2 diabetes mellitus is that it often occurs due to the metabolic abnormality leading to the development of it. The person who is having diabetes has subsequent disruption of normal glucose homeostasis. The insulin resistance has occurred as the first sequence of the abnormalities that lead to face these problems in glucose utilization by the cell. Insulin resistance is compensated by increasing insulin secretion which allows glucose metabolism to be impaired. Leading to delay and provide insufficient insulin secretion. The decreasing activity of the beta-cells the insulin resistance first develops the postprandial hyperglycemia.

Considering the nursing case study, it can be stated that complications of type2 diabetes mellitus are the hypoglycemia that is very low blood glucose and hyperosmolar hyperglycemic non-ketotic syndrome in which the blood glucose decreases extremely. This is considered as the short term complication of type2 diabetes. The long term complications of type2 diabetes are diabetic retinopathy, nephropathy, and diabetic neuropathy, and macrovascular problems (Perkovic et al., 2019).

The 3 levels of treatment that can help to cure type 2 diabetes mellitus are medication, exercises, and diet modification. There is medication available for the type2 diabetic patient like the metformin, it is considered as the best medication for lowering down the glucose production in the liver and improve individuals body to be less sensitive to the insulin letting, the insulin to utilize the glucose more effectively(American Diabetes Association, 2017). The exercise such as the aerobic exercise helps to reduce the weight as well as help the body to utilize the excess glucose present in the blood. The more the cell will be utilizing the glucose for cellular energy the lesser will be the glucose in the blood. Hence, it is stated in the nursing case study analysis that type2 diabetic Mellitus person is suggested to do some sort of exercise to make the glucose to be utilized by the body in producing cellular energy. The diet modification also plays an important role in maintaining the glucose level of the blood. As fatty foods contain a high level of fats and carbohydrates, excess fat and carbohydrates metabolism let to produce a high level of glucose for the cells. The more intakes of the fat and carbohydrate-rich food will be considered the more it would increase the level of glucose in the body (Neal et al., 2017).

1.2. Difference between the type 1 and type 2 diabetes mellitus

1.3. The two reasons that the Blood glucose level (BGL) of the Emily smith was high at the time of the admission as mentioned in the nursing case study were the high level of the stress she was having and the intake of ice cream which is which contains a high level of the carbohydrates in it. The stress works as insulin resistance and impaired insulin secretion to be utilized by the body. It impaired the hepatic glucose metabolism coupled with the activation of the inflammation pro-inflammation cytokines. In stressful conditions, the cell required more amount of glucose, but the insulin resistance of the cells let the produced glucose be unutilized by the cells which lead to an increase in the blood glucose level (BGL). The ice cream is consisting of a high amount of carbohydrates and fat, the metabolism involved in the lead to produce a high level of glucose in the blood. When a high carbohydrate food is eaten up, the digestive system breaks down the digestible ones into the sugar, which enters the blood leading to an increase in the glucose level in the blood. As the glucose level of the sugar arise the pancreas produces insulin, which helps the cells to absorb the sugar from the blood in non-diabetic patients. As in diabetic case like Emily Smith, there is an impairment related to the insulin, the blood glucose is not being utilized by the body. Hence, increases the blood glucose level (BGL) of her. Stress, as well as the eating of the high level of the glucose, leads her to produce an excess of the glucose by the beta cells of the pancreas, due to the impairment of the glucose utilization mechanisms of Emily smith, the glucose remained suspended in the blood (Rawshani et al., 2017). The unutilized glucose led to an increase in the level of glucose in the blood.

Part 2
2.1. Cortisone injection (Kenacort-A 40)
The action of the Kenacort-A 40 is related to the cure of arthritis. The action of the medication led to reducing the level of pain in the muscles, joints, or tendons. It is administrated within the body directly with the help of the injection. This suppresses the inflammation and swelling of the area (Abdeldayem, Mohamad, Shaker & Ali, 2016).

Considering the scenario of patient within the nursing case study, side effects or complications of the Kenacort-A 40 are several in number such as the allergic reaction, sleep problems. Mood swings, headache, dizziness, and nausea. Irregular menstrual periods, thinning of hair, usual sweating, and redness are also the side effect of the Kenacort-A (Laemmel et al., 2016).

Nursing considering for the intake of the Kenacort-A to Emily Smith would be ensured that the Emily smith should not be suffering from chills and fever, fast heartbeat, and any kind of breathing difficultly or shortness of breath. If she is feeling dizzy or light-headed, she should avoid taking the medication.

Metformin
The metformin belongs to the group of medicine called biguanides. It helps the body to utilize the glucose by making better use of the insulin produced by the pancreas. The metformin works over the liver, as it reduces the production level of the insulin there. This makes it easier for the glucose to enter into the tissues of the body, and limit the use of the glucose. The tablet provided to the patient mentioned in the nursing case study shows actions especially for the person who is overweight and having diabetes mellitus (Rena, Hardie & Pearson, 2017).

The side effect or complications of the metformin are that heartburn, stomach pain, bloating in the stomach, and nausea. Along with that, it also causes gas, diarrhea, constipation, weight loss, and headache. At some point, it also causes an unpleasant metallic taste in the mouth.

The nursing consideration would be checking the urine or serum glucose level frequently to undertake the conditions of the blood glucose level. Besides that, it should be ensured that every time Emily smith should carry some of the glucose-containing products near to her (McCreight, Bailey, & Pearson, 2016).

Glipizide
Glipizide act on partially blocking the potassium channels among the pancreatic islets of the beta cells of the Langerhans. It blocks the potassium channels resulting in the calcium influx which ultimately increases the insulin release from the beta cells. This is how the Glipizide helping in reducing the blood sugar level in the body of Emily smith (Correa, Rodrigue &Nappe, 2019).

The side effects of Glipizide are that it causes diarrhea, constipation, gas, and drowsiness. There is a chance of having tremors and rashes over the skins. She might feel hungry, anxious, and shaky. The intake of the medication can also lead to speed up the heart as well as sometimes it causes sweating. (Swati, Suma, Prasanna, Kusuma & Sri, 2020).

The nursing consideration for incorporating the medicine would be ensuring that it should be taken at 30 min before breakfast. Along with that, it monitors the urine or serum glucose to ensure the present condition of the blood glucose.

2.2. On admission, the blood glucose level was 22.9mmol/L and HbA1c was 11%. The normal level should be ranging from the 4 to 5.4 mmol/ fasting, and after 2 hours of eating the blood glucose level should be up to 7.8mmol/L. During the admission, her blood glucose level was high; hence, as the blood glucose level was high is it is obvious that the HbA1c would also be high. The Hba1c refers to the glycated hemoglobin which determines when the hemoglobin combines with the glucose in the blood, becoming glycated. Considering the readings of nursing case study, it can be stated that the normal range of the glycated hemoglobin is less than 6.5%, Emily smith is having 11% on the time of the admission which indicates that the smith is having a high level of glucose. As she was not taking any kind of medication to lower the sugar, hence this has led her blood sugar level to increase extremely. While after the surgery Emily smith's blood glucose level was 8.8mmol/L, which indicates that intake of metformin is letting the production of the insulin in the liver be reduced. The reduced production led to a decrease in the presence of glucose in the blood as well as the HbA1c to be reduced to 8.

Part 3
Emily smith's renal function indicates that she is suffering from a sort of kidney disorder. As the glomerular filtration rate seems to be decreased from the normal range indicates that the kidney filtration rate has been reduced. The body is not able to filter the blood, hence is not able to excrete the waste material from the body. The serum potassium level is 5.7mmol/L which is quite high, which indicates the potassium that should be completed excreted out of the body is somehow depositing in the blood due to the improper kidney function (Kumari, Mohan & Muthukumar, 2019). The serum urea and Creatinine are 17mmol/L and 150µmol/L, which is related to each other as both these components participate in the urea cycle. The increase in the components in the blood indicates that there is a malfunctioning of the renal, which is unable to execrate the component fully out of the body. The renal conditions of Emily smith indicate that she is suffering from chronic kidney failure. The appropriate treatment for chronic kidney failure would be available for Emily is dialysis or kidney transplantation of the kidney. The rationale for the treatment is that dialysis will work as an artificial kidney for Emily smith and will allow filtering the blood and excreting out all the material that is depositing in the blood (Razmaria, 2016). And another option that is kidney transplantation would lead to replacing the whole renal functioning and would be working very well within the body. The process would not require to regularly come to the hospital, as that is required in the dialysis.

Conclusion
From the above discussion done on the given nursing case study, it can be concluded that Emily smith is suffering from type 2 diabetes due to any of the reasons among overweight or genetic influence. The prolonged intake of the medication is leading her to face complications related to renal function disorder, which is very common in diabetic patients.

Reference
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